DOI: 10.1111/jdv.

13743 JEADV

SHORT REPORT

Epidemiology of post-adolescence acne and adolescence

acne in Singapore: a 10-year retrospective and comparative
study
X.D. Han,* H.H. Oon, C.L. Goh
The National Skin Centre (NSC), 1 Mandalay Rd, 308205, Singapore
*Correspondence: X.D. Han. E-mail: debra.han@mohh.com.sg

Abstract
Introduction Acne vulgaris commonly affects adolescents. But recent reports suggest a rising prevalence of post-ado-
lescence acne. While there are few reports on post-adolescence acne, there are even fewer reports comparing adoles-
cence acne and post-adolescence.
Methods Epidemiological data of adolescence (<25 years) and post-adolescence (≥25 years) acne patients diagnosed
between 2004 and 2013 in a tertiary dermatology referral centre was analysed. From the pool of patients seen in 2010,
80 adolescence and 84 post-adolescence acne patients’ epidemiological characteristics and treatment responses were
analysed.
Results During the 10-year study period, there was an increase in the number and proportion of acne cases. In 2004,
4447 (5.77%) of all new diagnoses made were of acne vulgaris. The proportion rose to 5723 (8.13%) in 2013. There were
consistently more female than male acne patients. The proportion of post-adolescent cases remained constant at about
30% of all acne patients seen. Mean age of acne vulgaris patients decreased from 23.1 years in 2004 to 22.6 years in
2013. In the subgroup analysis, there were more males than females with adolescence acne (61.3% vs. 38.8%,
P < 0.01) and more females with post-adolescence acne (69.0% vs. 31.0%, P < 0.01). Thirty-four (40.5%) post-adoles-
cence acne patients had acne from adolescence persisting into adulthood. Comedonal acne was more prevalent in the
adolescence acne patients (58.8% vs. 40.5%, P = 0.019), whereas cystic acne was more prevalent in post-adolescence
patients (18.1% vs. 7.5%, P = 0.044). Systemic retinoids were more often used for treatment in the adolescence acne
patients than post-adolescence acne patients (23.8% vs. 10.7%, P = 0.027).
Conclusion Acne predominantly affects adolescents but post-adolescence acne is not uncommon. For post-ado-
lescence acne, females predominate over males. Inflammatory and cystic acne tends to be more predominant in
post-adolescence acne patients, whereas comedonal acne is more often seen in adolescence acne patients.
Received: 19 August 2015; Accepted: 31 March 2016

Conflicts of interest
Dr H.H. Oon has served as a speaker for Galderma and received honoraria. The rest of the authors report no
conflict of interest.

Funding sources
None received for this study.

Introduction 24 years old.2–4 Post-adolescence acne can be divided into

Acne vulgaris is a common condition in adolescents. In recent
years, the prevalence of post-adolescence acne has been
reported to have increased.1 While the World Health Organi-
zation defines adolescents as those between 10 and 19 years
old, adolescence acne vulgaris is generally defined as acne
occurring in patients below 25 years of age, and post-adoles-
cence acne as acne vulgaris occurring in patients above
adult-onset acne and adult persistent acne, the latter referring
to acne that persisted since adolescence.5
Methods
The epidemiology of acne vulgaris cases seen at a tertiary derma-
tology referral centre was compared to that of the general case
population at the same centre for the years 2004–2013.

JEADV 2016 © 2016 European Academy of Dermatology and Venereology

2 Han et al.

The adolescence acne group consisted of patients aged below Female post-adolescent acne
Male post-adolescent acne
25, and the post-adolescence acne group includes those who Female adolescent acne
were 25 years and older. 3000 Male adolescent acne

More in-depth data analysis on the epidemiology and features 2500

Number of patients
such as duration, severity and distribution of acne and treatment
2000
history was performed on a subset of patients randomly selected
1500
from patients diagnosed with acne vulgaris in 2010 using a ran-
dom number generator on Microsoft Excel (2007 version). Year 1000

2010 was chosen to give sufficient period after the initial diagno- 500
sis of acne vulgaris to follow-up on treatment. 0
Severity of acne was classified as mild, moderate or severe

04
05
06
07
08
09
10

12
13
11
20
20
20
20
20
20
20
20

based on the Combined Acne Severity Classification, developed
by the Agency for Healthcare Research and Quality.6 This classi-
fication takes into account the numbers of comedones, inflam-
matory lesions, cysts and total lesion count. It is a subjective,
qualitative scale developed as a modification of the Investigator
Global Assessment for clinical trials in acne and was validated by
a strong correlation with Leeds grading, a pictorial acne grading
system.6,7
All patients had their type and number of acne lesions
recorded by their attending doctors, who were either dermatolo-
gists or resident trainees in dermatology. The severity of acne
vulgaris for each patient was derived from this scoring system.
Results
Between 2004 and 2013, Singapore’s population increased from
4.2 to 5.4 million, but the total number of new patients seen in
our centre decreased from 77 062 in 2004 to 70 416 in 2013. All
patients were referred patients as our centre is a national tertiary
dermatology referral centre. Despite the decline of new patient
attendances in our centre during the study period, the number
of acne vulgaris cases seen had increased from 4447 (5.77% of all
new attendances) to 5723 (8.13% of all new attendances). The
proportion of post-adolescence acne cases remained constant at
approximately 30% (range 29.9–34.4%) of all the acne vulgaris
cases seen.
During the 10-year study period, there were consistently more
females than males with acne vulgaris (range: 50.5–54.3% vs.
45.7–49.5%). In 2013, there were 2963 female acne cases vs. 2759
20
20
Years
Figure 1 Year-on-year comparison of adolescence and post-
adolescence acne patients by gender.
male cases. Although female patients consistently made up the
majority of acne vulgaris cases, there was a decline over the years
from 54.3% in 2004 to 51.8% in 2013 (Fig. 1).
Throughout the study period, there were more males with
adolescence acne vulgaris (range: 53.2–57.9%) compared to
females (range 42.1–46.8%). There were more females with
post-adolescence acne vulgaris, (range 64.1–69.6%) compared to
males (range 30.4–35.9%).
The number of acne vulgaris cases in all races increased dur-
ing the 10-year study period (Table 1). Among the races, the
Chinese had the highest increase in number and proportion of
acne vulgaris cases (3569–4312 cases). The proportion of Chi-
nese with acne vulgaris was 4.6% of all new attendances in 2004
and 6.1% in 2013. The ethnic distribution of new patients seen
in our centre in 2010 was similar to the ethnic distribution of
patients diagnosed with acne vulgaris between 2004 and 2013.
Countrywide population census in 2010 showed an ethnicity
mix of 74.1% Chinese, 13.4% Malays, 9.2% Indians and 3.3%
other races.8 In patients with acne vulgaris, the Chinese, who
formed the majority ethnic group were slightly over-represented
with an under-representation of the Malays.

Table 1 Racial distribution of patients in our centre diagnosed with acne vulgaris compared with all new patients seen in the centre (all
diagnoses) and countrywide population

Acne vulgaris patients All patients Country

(all diagnoses) population
Year
Race
2004 2013 2010 2010
Total (% of total) Chinese 3569 (80.3%) 4312 (75.3%) 41369 (74.7%) 74.1%
Indian 245 (5.5%) 430 (7.5%) 5158 (9.3%) 9.2%
Malay 286 (6.4%) 310 (5.4%) 3086 (5.6%) 13.4%
Others 342 (7.7%) 669 (11.7%) 5734 (10.4%) 3.3%
Unknown 5 (0.1%) 2 (0.0%) N.A N.A
Total 4447 (100%) 5723 (100%) 55 347 (100%) 100%

JEADV 2016 © 2016 European Academy of Dermatology and Venereology

Comparison of adolescence and post-adolescence acne vulgaris 3

Table 2 shows more detailed comparison of the characteristics
of adolescence and post-adolescence acne patients in the random
cohort of 164 patients (80 adolescents, 84 post-adolescents)
selected from a total of 5803 patients diagnosed with acne vul-
garis in 2010. This subgroup accurately represented the age, eth-
nicity and gender distribution of the patients seen in our centre
within the 10-year study period (Table 3).
Comedonal acne was more prevalent in patients with adoles-
cence compared to those with post-adolescence acne (58.8% vs.
40.5%, P = 0.019). Cystic acne was more prevalent in patients
with post-adolescence than those with adolescence acne (18.1%
vs. 7.5%, P = 0.044). Systemic retinoids were more often used in
treating patients with adolescence acne than those with post-
adolescence acne (23.8% vs. 10.7%, P = 0.027). However, it was
observed that there was no significant difference in treatment
outcome between the two treatment groups (P = 1.000, data not
shown). Thirty-four (40.5%) of 84 post-adolescent acne patients
had acne that persisted from their adolescent years. Clinical
characteristics of acne vulgaris were compared between this
adult persistent acne group and the adult-onset acne group.
Truncal acne occurred more often in those with adult persistent
acne than adult-onset acne (29.4% vs. 12.0%, P = 0.046).
Patients with adult persistent acne tend to have more pustular
lesions (50% vs. 24%, P = 0.014).

Table 2 Comparison of clinical characteristics and treatment Discussion

between the adolescence and post-adolescence acne groups Our findings are consistent with the general perception that acne
vulgaris predominantly affects adolescents. Recent reports
Adolescence Post-adolescence
Sample characteristics acne (N = 80) acne (N = 84) P value appear to indicate that there has been an increase in the preva-
Demography lence of post-adolescence acne in recent years.1,9 Two large stud-
Mean age (years) 19.2 31.0 N.A ies by Dreno B et al.10,11 reported that acne vulgaris is affecting
Female gender 38.8% 58.4% <0.001 an increasing number of adult women, posing a new treatment
Chinese race 80.0% 75.0% 0.444 challenge as it tends to run a more chronic course. In our study,
Type of acne the increase in the proportion of acne vulgaris patients in our
Persist from teen N.A 40.5% N.A tertiary dermatology referral centre was contributed by an
to adulthood increase in both adolescence and post-adolescence acne cases.
Comedonal 58.8% 40.5% 0.019 The proportion of post-adolescence acne vulgaris cases has
Cystic 7.5% 18.1% 0.044 remained relatively constant over the years at about 30% of the
Pustular 46.3% 34.5% 0.126
total acne vulgaris cases each year.
Papular 86.3% 90.5% 0.398
Our findings indicate that post-adolescence acne affects pre-
Scars 45.2% 36.9% 0.291
dominantly females. Female acne has been widely discussed in
Severity of acne
the literature. It is often characterized as acne occurring in
Mild 65.0% 75.0% 0.358
women aged >24 years4 and usually of mild to moderate severity
Moderate 28.7% 20.2%
with generally fewer acne lesions compared to adolescence acne.
Severe 6.3% 4.8%
It has been postulated to be due to hormonal factors12,13 in those
Treatment
Systemic retinoid 23.8% 10.7% 0.027
with a genetic predisposition,1,14 and environmental triggers. A
Systemic antibiotic 80.0% 71.4% 0.201
well-known observation is the link between female acne and the
Trial of both systemic 17.5% 3.6% 0.004 use of pro-androgenic progestin.15 In addition, dehy-
retinoids and droepiandrosterone sulphate (DHEA-S) has been reported to
antibiotics play a key role in the pathogenesis of adult-onset acne.12 In
Those values that are in bold are P values that are statistically significant. patients with adult-onset acne and features of

Table 3 Comparison of age, ethnicity and gender distribution between the subgroup analysis patients in 2010 and all patients diagnosed
with acne vulgaris in 2010

Subgroup analysis patients All acne vulgaris patients in 2010

Adolescent Post-adolescent Adolescent Post-adolescent
Age (mean) 19.2 31 18.6 32
Gender Male (%) 49 (61.3) 26 (31.0) 2304 (56.6) 571 (32.9)
Race Chinese (%) 64 (80.0) 63 (75.0) 3241 (79.6) 1221 (70.5)
Malay (%) 7 (8.8) 3 (3.6) 289 (7.1) 97 (5.6)
Indian (%) 3 (3.8) 7 (8.3) 237 (5.8) 147 (8.5)
Others (%) 6 (7.5) 11 (13.1) 251 (6.7) 268 (15.5)

JEADV 2016 © 2016 European Academy of Dermatology and Venereology

4 Han et al.
hyperandrogenism, measurement of circulating androgens,
including DHEA-S may help as hormonal therapy may be an
option.
Adolescence acne tends to manifest with more comedonal
and inflammatory lesions, whereas post-adolescence acne with
more inflammatory lesions with little comedones.13 Our study
confirmed that comedonal acne was more common in the ado-
lescent group. Our post-adolescence acne patients had more cys-
tic acne, similar to findings in a study by Capitanio et al.16 on a
variant of facial acne called comedonal post-adolescent acne,
where there are large comedones, cyst-like comedones and cysts.
The principles of treatment of adolescence and post-adoles-
cence acne are the same.17 Topical treatments and oral antibiotics
are usually used in treating mild to moderate acne and systemic
isotretinoin in severe cases. Systemic isotretinoin is often pre-
scribed only after a patient has failed treatment with oral antibi-
otics. Generally, post-adolescence acne tends to be more
refractory to conventional anti-acne treatment.2,13 But our find-
ings showed that more adolescence acne patients needed oral iso-
tretinoin than patients with post-adolescence acne. Our findings
also showed that none of our male patients with post-adolescence
acne required oral isotretinoin, whereas 5.2% of the female
patients with post-adolescence acne required oral isotretinoin.
Conclusion
While the number of new patients seen in the centre had
decreased in the period under study, the number and propor-
tion of patients seen for acne vulgaris had actually increased
in our Centre. While acne vulgaris mainly affects adolescents,
post-adolescence acne is not uncommon, representing 30% of
acne vulgaris cases seen. Post-adolescence acne tends to mani-
fest with more inflammatory and cystic lesions and less come-
donal lesions. While treatment regimens between the two
types of acne are similar, attention should be paid to the
fact that post-adolescent acne may be more recalcitrant to
treatment.
JEADV 2016
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